Clinical Scenarios

PPCI and Direct Admission of High Risk NSTE-ACSBeardmore Hotel

17th February 2016

Scenario 1

• SAS call to office on Sauchiehall Street• 50 year old male

o Chest tightness for 30 minso “It must be the fry-up”o Associated sweating and nauseao Recent history of increasing exertional chest

discomfort• Hypertension, smoker• “On tablets for blood pressure”

A Talking in full sentencesB RR 18, Sp02 96% OA, chest clearC HR 85, BP 175/95, clammyD AVPUE T 36.5, BM 7.9, nil else

What would you do next?

1. Call GJNH2. Take to local A+E3. Initiate medical therapy4. Reassure and leave

What would you do next?

1. Call GJNH2. Take to local A+E3. Initiate medical therapy4. Reassure and leave

2 2 1 1 ?6High risk NSTEMI

✔ ✔ ✔✔

GJNH

Scenario 2

• SAS call to Christmas party in Merchant’s City• 40 year old male

o Chest tightness and palpitations for the past 1 hour

o “I love a free bar pal”• Admits to frequent episodes of palpitations

recently – has been seen in clinic• On simvastatin

A Talking in full sentencesB RR 18, Sats 98% OA, chest clearC HR 160, BP 120/75, well-perfusedD AVPUE T 37.2, BM 4.2, nil else

What does this ECG show?

1. Narrow complex tachycardia2. Atrial fibrillation3. Rate-related ischaemia4. All of the above

What does this ECG show?

1. Narrow complex tachycardia2. Atrial fibrillation3. Rate-related ischaemia4. All of the above

What further information would be useful?

1. HEART Score2. More detailed social history3. Clinic letters4. All of the above

What further information would be useful?

1. HEART Score2. More detailed social history3. Clinic letters4. All of the above

Cardiology clinic 01/12/15:

“I saw this man in clinic today. He has a 6-month history of intermittent palpitations. These are associated with excessive alcohol intake. I have organised a 24 hour ECG recording and will see him back with the results in 3 months.”

?3

0 2 0 1

PAF with rate-related ischaemia

Local A&E

Scenario 3

• SAS call to nursing home in Partick• 89 year old female

o Gradual increase in SOB over past 2 weekso “I can hardly sleep”o No chest pain

• “She’s had a heart attack before and has a weak heart”

• On aspirin, ramipril, bisoprolol, simvastatin

A Broken sentencesB RR 28, Sats 85% OA, crackles bilaterally, C HR 96, BP 110/90, cool peripherallyD AVPUE T35.9, BM 5.5, peripheral oedema

What does this ECG show?

1. NSTEMI2. STEMI3. LBBB4. RBBB

What does this ECG show?

1. NSTEMI2. STEMI3. LBBB4. RBBB

What further information would be most useful?

1. Lactate2. Detailed family history3. Medication doses4. Old ECGs

What further information would be most useful?

1. Lactate2. Detailed family history3. Medication doses4. Old ECGs

What is the most likely diagnosis?

• NSTEMI• Decompensated heart failure• Pulmonary embolism• Respiratory tract infection

What is the most likely diagnosis?

• NSTEMI• Decompensated heart failure• Pulmonary embolism• Respiratory tract infection

DNACPR in place since July 2015. Patient and family do not wish any further invasive investigations.

Summary

• Rapid identification of high-risk NSTEMI• Early discussion with GJNH• Recognition of type 2 myocardial infarctions• Thorough information-gathering• Better outcomes for patients